Patient Information and Consent (V2.0) © SBS Dental Group

Consent to Dental Photography In connection with dental services, which I am receiving from Dr Manish Patel / Dr Amit Chudasama, I agree and consent to allow the photographs taken before, during, and after completion of my dental treatments to be used for dental records, research, education, public relations, patient counselling or other purposes. I further agree and consent that the photographs relating to my dental care may be published and re‐published, either separately or in connection with each other in dental photo albums, professional journals, or dental books.

Name of Patient _________________________________ Date _____________

Signature ______________________________________

Witnessed by ___________________________________ Date _____________